II. Definition: Recovery Audit Contractor (RAC)

  1. Private auditors contracted by government to recover "over-billing" dollars
  2. Auditors receive incentives for recovery and awarded higher bounty for greater recovery
    1. Review is often based on software mining and assign error rates based on certain number of charts (e.g. 100)
    2. Error rate is then extrapolated over prior years and revenue loss for facilities can be substantial based on small reviews

III. Background: Four contractor regions in U.S.

  1. Health Data Insights (West)
  2. CGI (Midwest)
  3. Diversified Collection Services (Northeast)
  4. Connolly Consulting Inc (South)

IV. Pitfalls: Avoid boiler-plate, cloned exams

  1. History
    1. Document 4 HPI components with case specific detail
    2. Note review of PMH, Family History and social history
    3. Review and summarize old records
    4. ROS should include 2-3 pertinent positives and negatives
  2. Exam
    1. Do not over-document exam
    2. Review nursing data and note this
  3. Assessment
    1. List the contributing co-morbidity and complexity
    2. Document high risk diagnoses (e.g. Altered Level of Consciousness)
    3. Document response to treatment and reviewed results (play-by-play)
      1. Document independent interpretation of results
      2. Document discussion with other providers
    4. Document summary of findings
    5. Document differential diagnosis
  4. Document critical care
    1. Do not minimize
    2. Explain clearly the system/organ that is in failure
      1. Contrast with a level 5 visit where there is a risk of organ failure
    3. Explain the critical interventions
    4. Document critical care minutes (80% are <74 minutes)

V. References

  1. Granovsky (2012) MN ACEP Reimbursement and Coding Conference, Minneapolis
  2. Johnson (2012) MN ACEP Reimbursement and Coding Conference, Minneapolis

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